I would like to receive more information

If you are between the ages of 18 and 65 and are interested in being a participant in our research studies, we invite you to fill out the form below. You will be compensated at least $10.00 per hour for participating. Sessions last 3 to 4 hours and we are happy to discuss arranging multiple sessions. We will be contacting you in a couple of days following receipt of the information you have provided. If you do not hear from us within one week, please do not hesitate to call the lab at 1-847-491-2457. ANY INFORMATION PROVIDED WILL BE KEPT CONFIDENTIAL.

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General Information

First Name and Last Initial*:

Age*:

Zip Code*:

Day Time phone (including area code):

Evening phone (including area code):

E-mail*:

Language Information

Are you a native English speaker?:

No
Yes

If you are not a native English speaker, at what age did you begin learning English?:

Do you speak any languages other than English?:

No
Yes

If yes, what language(s)?:

Level of fluency on a scale of 1(novice) to 5(expert)?

At what age did you begin speaking language?

Musical Experience

Do you play any instruments?

No
Yes (If yes, please list the instrument (including vocals)):

Instrument 1:

Years of experience:

Years of consist practice:

Age began playing instrument:

Level of expertise for this instrument:

Beginner
Intermediate
Advanced
Professional

Instrument 2:

Years of experience:

Years of consist practice:

Age began playing instrument:

Level of expertise for this instrument::

Beginner
Intermediate
Advanced
Professional

Instrument 3:

Years of experience:

Years of consist practice:

Age began playing instrument:

Level of expertise for this instrument:

Beginner
Intermediate
Advanced
Professional

Hearing Ability

Do you have any hearing loss?

No
Yes

If yes, please describe:

Please list all situations where you have difficulty with your hearing:

On the telephone:

No
Yes

In conversation with one person:

No
Yes

In a group:

No
Yes

In noisy situations:

No
Yes

When people talk to fast:

No
Yes

In large rooms/auditoriums:

No
Yes

Other (please specify):

Please help us by answering a few optional questions:

How did you hear about our lab?

What convinced you to want to partcipate?

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Thank you for signing up with us today and answering our questions. Please feel free to share our sign-up page and invite others to participate in our studies.